DFW Implant Team: MEDICAL AND DENTAL HISTORY

MEDICAL AND DENTAL HISTORY

This information is request in order that Dr. Donald Steinberg and his staff at DFW Implant Team may thoroughly diagnose and treat your condition safely.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number
Please enter a valid phone number.
Business Number
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Marital Status
Spouse Name

First NameLast Name
Email
example@example.com
SS#
Weight lbs e.g. 175
Height ft e.g. 5 inch e.g. 07
Employment Information (please write "unemployed" or "retired" if applicable):
Primary Care Physician/s
Phone Number
Please enter a valid phone number.
Dentist
Phone Number
Please enter a valid phone number.
Referred By
Insurance and Emergency Contact Information
Name of Insured
Birth Date

MonthDayYear
SS#
Employer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Dental Insurance
Person Responsible for Payment

First NameLast Name
Emergency Contact

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Health History and Conditions

Please select "Yes" or "No" to indicate whether or not you have the following health conditions.*

	Yes	No
Epilepsy
Kidney Disease
Often thirsty
High Blood Pressure
Chest Pains
Shortness of Breath
Prolonged Bleeding
Radiation Treatment
Psychiatric Treatment
Sinus Problems
Stomach Ulcers
Asthma
Do you use an inhaler?
Thyroid
Tuberculous
ARE YOU: Presently under the care of a physician?

Have you had Heart Trouble/Atrial Fib?

YesNo
If yes, please describe.
Have you had a Stroke?

YesNo
If yes, when?
Have you had Hepatitis?*

Type AType BType CNo
Do you have any of the following bone conditions?*

OsteopeniaOsteoporosisArthritisNone of the above
What type of arthritis?
Do you have or have you ever had cancer?*

YesNo
What type and when?
Do you have Diabetes?*

YesNo
If yes, what type and when were you diagnosed?
Do you have an Autoimmune disease or HIV?*

YesNo
If yes, what type?
Are you currently under the care of a physician?*

YesNo
Date of last physical

MonthDayYear
Date
Please List Names of Any Current Medications (including prescription and over the counter; or type "n/a" if none)*
Please List Any Previous Surgeries (or type "n/a" if none)*
Have you taken Bisphosphonates?*

YesNo

Have you had an unfavorable or allergic reaction to the following drugs?*

Please select "Yes" or "No" for each of the following conditions.*

Do you smoke, use e-cigarettes or tobacco?*

Current smokerPast smoker, but quitTobacco userPast tobacco user, but quitE-cigarettesNo
If yes, how much per day?
When did you quit?
Do you drink:*

CoffeeAlcoholNone of the Above
How much per day?

Please select "Yes" or "No" for each of the following DENTAL HEALTH conditions.*

	Yes	No
Aware of grinding or clenching
Treated for gum disease
Had braces/orthodontics
Jaw popping or pain
Bad breath
Bleeding gums
Tooth sensitivity (Heat/Cold)
Use water pik
Taught oral hygiene care
Tooth loss concern
Considered implants

MEDICAL AND DENTAL HISTORY